Clinical and angiographic results after hybrid coronary revascularization

Robotic Totally Endoscopic Reverse Hybrid Coronary Revascularization: Early and Midterm Outcomes

OBJECTIVE

Reverse hybrid coronary revascularization (RHCR) is the integration of percutaneous coronary intervention (PCI) followed by sternal-sparing coronary artery bypass grafting in patients with multivessel coronary artery disease (CAD). We sought to review our RHCR experience over a 10-year period using PCI first followed by robotic totally endoscopic coronary artery bypass (TECAB).

METHODS

We reviewed the indications and outcomes in patients who underwent RHCR (PCI with drug-eluting stents first, followed by TECAB).

RESULTS

From July 2013 to August 2024, 882 robotic TECAB procedures were performed at our institution. Of these, 60 patients underwent RHCR. The mean age of the patients was 66.7 ± 10 years, and 74% were male patients. The target vessel stented was the right coronary artery in 52 patients (87%), circumflex coronary artery in 10 patients (17%), and diagonal in 4 patients (7%). The average time from PCI to TECAB was 3.8 ± 1.64 months. A total of 35 patients (58%) underwent multivessel grafting, with 74% bilateral internal thoracic artery (ITA) use. The mean operative time was 253 ± 88 min, and the mean hospital length of stay was 2 ± 0.76 days. There were no conversions, perioperative strokes, or myocardial infarctions. At mean follow-up of 34 ± 27 months, cardiac-related mortality occurred in 1 patient. Freedom from major adverse cardiac or cerebrovascular events including repeat revascularization was 93%.

CONCLUSIONS

RHCR is safe and feasible in selected patients with multivessel CAD. In experienced hands, stenting first followed by robotic TECAB with left ITA or bilateral ITA grafts resulted in excellent early and midterm outcomes. Further studies are warranted.

Minimally Invasive Coronary Artery Bypass Grafting is the Future: Pro

Coronary artery bypass grafting (CABG) remains one of the most commonly performed operations worldwide. However, most CABG operations performed today are as invasive -apart from saphenous vein harvesting- as they were 50 years ago. While heart valve operations have become less invasive, CABG faces formidable challenges in doing so. Valve surgery requires a single surgical exposure to the valve intervened on, but less invasive CABG necessitates multiple surgical exposures to harvest internal thoracic artery conduits, source their inflow plus that of other grafts, and expose each coronary target to be grafted -including anterior, lateral, posterior, and inferior vessels. In this article, we rationalize why we believe that conventional CABG remains unduly invasive, associated with morbidity and prolonged recovery, and why less invasive CABG in its many forms, which we describe, represents a safe, practical, diffusible, and less invasive alternative to sternotomy CABG. Centers of excellence in coronary artery surgery should dedicate resources and expertise to developing high-quality, safe, durable, and advanced forms of lesser invasive CABG.

The Current State of Hybrid Coronary Revascularization

Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary artery disease. Despite decades of use, widespread acceptance has been limited. In this review, we conduct a comparative assessment of HCR in relation to traditional coronary artery bypass graft surgery and multivessel PCI. Although large-scale randomized data are still lacking, numerous studies have demonstrated that HCR may offer benefits regarding resource utilization and short-term morbidity while delivering comparable mid- and long-term survival compared with traditional bypass surgery. Compared with PCI, HCR may offer similar periprocedural morbidity while mitigating the need for repeat revascularization by providing a surgical arterial bypass graft to the left anterior descending artery.

Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS)

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.

Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions

Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.

Comparing clinical outcomes of hybrid coronary revascularization with open coronary artery bypass in patients with multi-vessels lesions

OBJECTIVES

Hybrid coronary revascularization (HCR) involves the use of minimally invasive direct coronary artery bypass grafting (CABG) to treat the left anterior descending artery (LAD), and percutaneous coronary intervention to treat non-LAD vessels. We reported the results of a comparative analysis between HCR and off-pump CABG via sternotomy (OPCABG).

METHODS

Data were retrospectively collated from patients who underwent HCR or OPCABG for multivessel coronary artery disease between 2011 and 2022. Propensity score-based matching was performed to reduce the selection bias. The Comparisons of cardiac-related death, major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization were performed by Kaplan-Meier analysis or the Fine-Gray test.

RESULTS

After matching, the baseline characteristics were well-balanced between the two groups with 91 patients per group. There was no significant difference in operative mortality rate (1.1% for HCR vs2.2% for OPCABG, p = 1.000). However, patients undergoing HCR required a significantly lower rate of blood product transfusions (p < .001) and experienced significantly fewer pulmonary complications than OPCABG patients (p < .001). At 10 years, the incidences of cardiac-related death, MACCE and repeat revascularization did not differ significantly between the two groups (9.5% vs11.5%, p = .277; 4.7% vs12.3%, p = .361; 1.2% vs2.5%, p = .914, respectively).

CONCLUSIONS

For patients with multi-vessel lesions, HCR was comparable to OPCABG in long-term outcomes such as cardiac-related death, MACCE, and the durability of grafts. Additionally, HCR was better than OPCABG in perioperative outcomes. HCR may be an alternative therapy for OPCABG in patients with multi-vessel coronary artery disease.

Examining the Outcomes of Hybrid Coronary Revascularization in Acute STEMI Patients from 2015 to 2022

Background

The global rise of chronic diseases, especially cardiovascular disease (CVD), poses a significant public health challenge, being a leading cause of death and disability worldwide. In Iran, the surge in CVD incidence and its risk factors, along with a decrease in the age of onset, has notably increased the reliance on coronary artery bypass grafting (CABG) as a life-saving intervention. Staged hybrid coronary revascularization (HCR), which combines percutaneous coronary intervention with delayed CABG, offers a novel approach for patients with complex coronary artery disease, potentially improving survival and reducing complications. Considering the newness of this treatment method and the limitations of previous studies, we investigated the results of staged HCR in acute ST-elevation myocardial infarction (STEMI) patients in this study.

Methods

This observational study was performed on consecutive patients with acute STEMI who underwent staged HCR and were referred to Valiasr and Razi hospitals in Birjand from 2015 to 2022. The required information (demographic information, angiography result, and operation side effects) was collected in a checklist. If necessary, the patients were contacted by phone. After collecting the data, they were entered into SPSS version 16 software.

Results

This study was conducted on 33 patients with a mean age of 64.88 ± 9.24 years (69.7% male). The average hospital stay was 11.6 ± 8.9 days (3 to 72 days). The mean ejection fraction and syntax score were 36.5% ± 10.2% and 31.21 ± 6.7, respectively. Following surgery and during hospitalization, arrhythmias were observed, including 33.3% with premature ventricular contractions, 18.1% with atrial fibrillation, and 3.1% with ventricular tachycardia. The average number of pack cells (red blood cells that have been separated for blood transfusion) and creatinine changes before and after hybrid surgery were 640.9 ± 670.9 cc and 0.055 ± 0.07. In the follow-up, 9.09% of patients had late mortality, 6.1% of patients had urinary tract infections during hospitalization, 6.1% of patients had surgical site infections, 3.1% needed dialysis, and none of the studied patients had premature death or need for reintervention.

Conclusions

The results of our study indicated that staged HCR performed early after an ACS is not associated with significant mortality or complications. Therefore, it is advisable to consider staged HCR as a surgical option in appropriate cases.

Minimal-Access Coronary Revascularization: Past, Present, and Future

Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms-namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated.

Minimally Invasive Direct Coronary Artery Bypass: An Evolving Paradigm Over the Past 25 Years

OBJECTIVE

We have routinely utilized minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery. We examined how this procedure has evolved.

METHODS

A retrospective review was undertaken of 2,283 consecutive patients who underwent MIDCAB between 1997 and 2021. Patients were divided into 3 groups: group A from 1997 to 2002 (n = 751, 32.9%), group B from 2003 to 2009 (n = 452, 19.8%), and group C from 2009 to 2021 (n = 1,080, 47.3%). Risk profiles and short-term outcomes were analyzed for the entire cohort and for 293 propensity-matched patients drawn from each group.

RESULTS

The left internal mammary artery was harvested open in group A but with robotic assistance in group C. Thirty-day mortality was higher in group A versus group C (12 deaths, 1.6% vs 5 deaths, 0.5%, P = 0.044); this difference was negated after propensity matching. Group A had more comorbidities than group C, including peripheral vascular disease (17.7% vs 10.0%, P < 0.001), congestive heart failure (39.6% vs 18.0%, P < 0.001), and a history of stroke (17.9% vs 10.0%, P < 0.001), although diabetes mellitus was more common in group C (51.4% vs 31.0%, P < 0.001). Stroke was greater in group A (1.2% vs 0.0% vs 0.2%, respectively, P = 0.004), as was the need for prolonged ventilation (3.6% vs 0.2% vs 0.9%, respectively, P < 0.001), before and after propensity matching.

CONCLUSIONS

MIDCAB patients had less comorbidities than in the past. Robot-assisted MIDCAB was associated with lower stroke risk.

Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI

OBJECTIVE

Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI.

METHODS

Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients.

RESULTS

The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%.

CONCLUSIONS

In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.

Clinical results after hybrid coronary revascularization with totally endoscopic coronary surgery

Background

The optimal revascularization strategy remains uncertain in multivessel coronary artery disease (MVCAD). The durability of the surgical grafts should be weighed against the decreased invasiveness of percutaneous coronary intervention (PCI). Hybrid coronary revascularization (HCR), a combination of PCI and surgery, could be a feasible alternative. This study aimed to investigate the occurrence of major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality after both endoscopic coronary artery bypass grafting (Endo-CABG) and the HCR procedure.

Methods

In this single-center retrospective observational study, 347 consecutive patients have been subjected to an Endo-CABG procedure, of which 103 underwent HCR between January 2016 and January 2018. A propensity score matching analysis was performed to match 103 Endo-CABG alone patients to the 103 HCR patients. The Endo-CABG procedure was performed through 3 endoscopic ports (5 mm) in the 2nd, 3rd, and 4th intercostal space and a utility port of 3 cm.

Results

In both the HCR and matched endo-CABG alone group, the 30-day mortality was acceptable (0% in the HCR group and 1.94% in the matched Endo-CABG alone group, p = 0.155). Additionally, the occurrence of MACCE after a mean follow-up of 1188 ± 538 days was similar in both groups (9.71% and 11.65% for the HCR and matched Endo-CABG alone group, respectively, p = 0.652). Still, the long-term all-cause mortality over this period was significantly higher in the matched Endo-CABG alone group (2.91% after the HCR procedure and 11.65% after matched Endo-CABG alone, p = 0.002).

Conclusion

HCR has some advantages over Endo-CABG alone regarding the all-cause mortality, cross-clamping time, intensive care unit, and hospital length of stay. Therefore, HCR may be a suitable alternative therapy for patients with MVCAD.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Robotic-assisted coronary artery bypass grafting: current knowledge and future perspectives

Minimally invasive direct coronary artery bypass grafting (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB) are the two existing strategies for robotic-assisted, surgical myocardial revascularization. In this review, we summarize the wide evidence available in the literature regarding the benefits of these two procedures, and detail the technical skills required to master robotic coronary surgery techniques.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

A review of hybrid coronary revascularization

Purpose

Hybrid coronary revascularization is an emerging treatment strategy for coronary artery disease. We will review the reasons for the development of this strategy, describe surgical techniques, and review outcomes. Finally, we will discuss the future of hybrid revascularization and explain why it will grow as a treatment modality.

Methods

For this review, we conducted an unstructured review of the literature for articles related to hybrid coronary revascularization, bypass surgery, and percutaneous coronary interventions.

Results

Hybrid coronary revascularization has been shown in large series to have excellent results. These include fast recovery time, low mortality and rates of complications, and excellent surgical graft patency. There may be increased need for revascularization over conventional bypass surgery.

Conclusions

The combination improved surgical techniques including a robotic surgery platform, as well as the ever-improving efficacy and durability of coronary stents have made hybrid coronary revascularization an attractive option for many patients. It offers a minimally invasive approach to surgery while avoiding the poor patency of saphenous vein grafts. In appropriately selected patients, this may be an ideal treatment strategy that minimizes risks and maximizes short- and long-term benefits.

Hybrid coronary revascularization for the treatment of multivessel coronary artery disease

Coronary artery disease (CAD) has typically been treated either medically, with percutaneous coronary intervention (PCI), or with coronary artery bypass grafting (CABG). As advances in stent technology and minimally invasive surgery have developed, a third option has emerged: hybrid coronary revascularization (HCR). In HCR, minimally invasive CABG and PCI are both employed to treat a single patient, often during the same hospital stay. Patients appropriate for this technique vary widely, from low-risk patients with low SYNTAX lesions outside the left anterior descending artery (LAD), to high-risk patients with multiple comorbidities who are felt by the heart team to benefit most by avoiding a sternotomy. Across both our experience and other series in the literature, mortality with HCR is around 1%. Hospital length of stay is less than one week, and typically less than after conventional CABG, but longer than with isolated PCI. Return to baseline activity is substantially shorter after minimally invasive CABG compared to conventional CABG due to the avoidance of a sternotomy; deep sternal wound infections are entirely avoided. Mid-term need for repeat revascularization may be higher with HCR, though randomized data are lacking. In conclusion, HCR is an evolving method to treat multivessel CAD with favorable early results in high volume centers, though growth in the field is limited by surgical experience and success with minimally invasive techniques.

Short-Term and Mid-Term Clinical Outcomes Following Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass: A Meta-Analysis

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) is one of the standard treatments for coronary artery disease (CAD) while hybrid coronary revascularization (HCR) represents an evolving revascularization strategy. However, the difference in outcomes between them remains unclear.

OBJECTIVE

We performed a meta-analysis to compare the short-term and mid-term outcomes of HCR versus OPCAB for the treatment of multivessel or left main CAD.

METHODS

We searched the PubMed, EMBASE, Web of Science and Cochrane databases to identify related studies and a routine meta-analysis was conducted.

RESULTS

Nine studies with 6121 patients were included in the analysis. There was no significant difference in short-term major adverse cardiac and cerebrovascular event (MACCE) rate (RR: 0.55, 95% CI: 0.30-1.03, p = 0.06) or mortality (RR: 0.51, 95% CI: 0.17-1.48, p = 0.22). HCR required less ventilator time (SMD: -0.36, 95% CI: -0.55- -0.16, p < 0.001), ICU stay (SMD: -0.35, 95% CI: -0.58 - -0.13, p < 0.01), hospital stay (SMD: -0.29, 95% CI: -0.50- -0.07, p < 0.05) and blood transfusion rate (RR: 0.57, 95% CI: 0.49-0.67, p < 0.001), but needed more operation time (SMD: 1.29, 95% CI: 0.54-2.05, p < 0.001) and hospitalization costs (SMD: 1.06, 95% CI: 0.45-1.66, p < 0.001). The HCR group had lower mid-term MACCE rate (RR: 0.49, 95% CI: 0.26-0.92, p < 0.05) but higher rate in mid-term target vessel revascularization (TVR, RR: 2.20, 95% CI: 1.32-3.67, p < 0.01).

CONCLUSIONS

HCR had similar short-term mortality and morbidity comparing to OPCAB. HCR decreased the ventilator time, ICU stay, hospital stay, blood transfusion rate and increased operation time and hospitalization costs. HCR has a lower mid-term MACCE rate while OPCAB shows better in mid-term TVR.

Minimally Invasive Multivessel Coronary Surgery and Hybrid Coronary Revascularization: Can We Routinely Achieve Less Invasive Coronary Surgery?

Coronary artery bypass grafting (CABG) is the gold standard in managing severe coronary artery disease. However, it is associated with prolonged recovery and potential complications, in part due to the invasiveness of the procedure. Less invasive CABG techniques attempt to improve the quality and quantity of life in the same way as surgical revascularization but with fewer complications. Minimally invasive coronary surgery (MICS) through a small thoracotomy allows for complete revascularization with good results in graft patency. Perioperative mortality is low, and there is decreased need for blood transfusion, lower surgical site infection rates, and an earlier return to full physical function. Hybrid coronary revascularization (HCR) attempts to combine the advantages of coronary artery bypass grafting with those of percutaneous coronary intervention. Several studies have shown that HCR provides better short-term outcomes with regard to decreased ventilation and ICU time, reduced need for blood transfusion, and shortened hospital stay. However, the rates for major adverse cardiovascular events and mortality are comparable to conventional CABG, except for patients with a high SYNTAX score who displayed increased mortality rates. There is also strong evidence of a higher need for repeat revascularization with HCR compared to CABG. Overall, MICS and HCR appear to be viable alternatives to conventional CABG, offering a less invasive approach to coronary revascularization, which may be especially beneficial to high-risk patients. This article discusses approaches that deliver the advantages of minimally invasive surgical revascularization that can be adapted by surgeons with minimal investment with regards to training and infrastructure.

Reviewing hybrid coronary revascularization: challenges, controversies and opportunities

Two main approaches to myocardial revascularization currently exist, coronary artery bypass and percutaneous coronary intervention. In patients with advanced coronary artery disease, coronary artery bypass surgery is associated with improved long term outcomes while percutaneous coronary intervention is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach. This new approach, hybrid coronary revascularization, has shown encouraging early results. Minimally invasive techniques for bypass surgery have played a large part of bringing this approach into contemporary practice.

Effects of total thoracoscopic surgery on coronary artery fistulae complicated with ectasia

Objective:

To compare the effects of thoracotomy and total thoracoscopic surgery on coronary artery fistulae complicated with ectasia.

Methods:

Forty-six patients with coronary artery fistulae complicated with ectasia were randomly divided into a treatment group and a control group (n=23) which were given totally thoracoscopic surgery and thoracotomy respectively. Both groups were followed up.

Results:

All patients survived the surgeries and were discharged from the hospital. The treatment group had significantly less intraoperative blood loss, earlier postoperative ambulation and shorter postoperative hospitalization stay more than those of the control group (P<0.05). The two groups had similar plasm cortisol and adrenocorticotropic hormone levels one day before and after surgery. These levels peaked on the postoperative 3rd day, but those of the treatment group were significantly lower (P<0.05). The two groups had similar left and right atrial diameters as well as left ventricular ejection fractions (LVEFs) before surgery, but the treatment group had significantly higher postoperative LVEF (P<0.05) as well as significantly smaller left and right atrial diameters in the postoperative 1st and 3rd months (P<0.05). The treatment group was significantly less prone to postoperative complications such as chest pain, atelectasis and pulmonary infection than the control group (P<0.05).

Conclusion:

Total thoracoscopic surgery promoted the recovery of coronary artery fistulae complicated with ectasia, improved cardiac remodeling and cardiac function, and alleviated stress reaction, with well-proved safety.

A novel approach to ischemic mitral regurgitation (IMR)

Ischemic mitral regurgitation (IMR) is a complicated medical condition with varying degrees of coronary artery disease and mitral regurgitation (MR). The traditional surgical treatment option for those with indications for intervention is coronary artery bypass grafting (CABG) plus or minus mitral valve repair or replacement (MVR). Percutaneous coronary intervention, hybrid coronary revascularization (HCR), and conventional CABG are three techniques available to address coronary artery disease (CAD). Percutaneous edge-to-edge repair, minimally invasive, and traditional sternotomy are accepted approaches for the treatment of MR. When taken in combination, there are nine methods available to revascularize the myocardium and restore competency to the mitral valve. While most of these treatment options have not been studied in detail, they may offer novel solutions to a widely variable and complex IMR patient population. Thus, a comparative analysis including an examination of potential benefits and risks will be helpful and potentially allow for more patient-specific treatment strategies.

Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era

BACKGROUND

The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong.

METHODS

Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization.

RESULTS

The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature.

CONCLUSIONS

Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.

Hybrid coronary revascularization versus coronary artery bypass grafting for multivessel coronary artery disease: systematic review and meta-analysis

BACKGROUND

The concept of hybrid coronary revascularization (HCR) combines the left internal mammary artery (LIMA)-left anterior descending (LAD) graft and percutaneous coronary intervention (PCI) to non-LAD vessels. Multiple comparative studies have evaluated the safety and feasibility of HCR and coronary artery bypass grafting (CABG) for multivessel coronary artery disease (MCAD). However, the sample size of each study was small, and evidences based on single-institutional experience. The purpose of this meta-analysis was to compare the short-term outcomes of HCR with those of CABG for MCAD.

METHOD

PubMed, EMBASE and Cochrane Library databases, as well as conference proceedings, were searched for eligible studies published up to March 2014. We calculated summary odds ratios (OR) for primary endpoints (death, stroke; myocardial infarction (MI); target vessel revascularization (TVR); major adverse cardiac or cerebrovascular events (MACCEs)) and secondary endpoints (atrial fibrillation (AF); renal failure; length of stay in the intensive care unit (LoS in ICU); length of stay in hospital (LoS in hospital); red blood cell (RBC) transfusion). Data from 6176 participants were derived from ten cohort studies.

RESULTS

HCR was non-inferior to CABG in terms of MACCEs during hospitalization (odds ratio (OR), 0.68, 95% confidence interval (CI), 0.34-1.33)and at one-year follow-up(0.32, 0.05-1.89) , and no significant difference was found between HCR and CABG groups in in-hospital and one-year follow-up outcomes of death, MI, stroke, the prevalence of AF and renal failure, whereas HCR was associated with a lower requirement of RBC transfusion and shorter LoS in ICU and LoS in hospital than CABG (weighted mean difference (WMD) -1.25, 95% CI, -1.62 to -0.88; -17.47, -31.01 to -3.93; -1.77, -3.07 to -0.46; respectively).

CONCLUSION

Our meta-analysis indicates that HCR is feasible, safe and effective for the treatment of MCAD, with similar in-hospital and one-year follow-up outcome, significantly lower requirement of RBC transfusion, and faster recovery compared with CABG.

Hybrid coronary revascularization: a systematic review

The hybrid approach to coronary revascularization is an evolving technique that is being used as an alternative to the traditional median sternotomy coronary artery bypass graft surgery. It combines a minimally invasive approach to bypass the left anterior descending coronary artery with a percutaneous approach to revascularize the other coronary arteries. A systematic review of the available literature was conducted to evaluate the benefits, and the short- and long-term outcomes of this procedure.

Clinical outcomes of hybrid coronary revascularization versus coronary artery bypass surgery in patients with diabetes mellitus

BACKGROUND

Hybrid coronary revascularization (HCR) involves minimally invasive left internal mammary artery to left anterior descending coronary artery grafting combined with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. The safety and efficacy of HCR among diabetic patients are unknown.

METHODS

Patients with diabetes were included who underwent HCR at a US academic center between October 2003 and September 2013. These patients were matched 1:5 to similar patients treated with coronary artery bypass grafting (CABG) using a propensity score (PS)-matching algorithm. Conditional logistic regression and Cox regression stratified on matched pairs were performed to evaluate the association between HCR and inhospital complications, a composite measure of 30-day mortality, myocardial infarction and stroke, and up to 3-year all-cause mortality.

RESULTS

Of 618 patients (HCR = 103; CABG = 515) in the PS-matched cohort, the 30-day composite of death, MI, or stroke after HCR and CABG was 4.9% and 3.9% (odds ratio: 1.25; 95% CI [0.47-3.33]; P = .66). Compared with CABG, HCR also had similar need for reoperation (7.6% versus 6.3%; P = .60) and renal failure (4.2% versus 4.9%; P = .76) but required less blood products (31.4% versus. 65.8%; P < .0001), lower chest tube drainage (655 mL [412-916] versus 898 mL [664-1240]; P < .0001), and shorter length of stay (<5 days: 48.3% versus 25.3%; P < .0001). Over a 3-year follow-up period, mortality was similar after HCR and CABG (12.3% versus 14.9%, hazard ratio: 0.94, 95% CI [0.47-1.88]; P = .86).

CONCLUSION

Among diabetic patients, the use of HCR appears to be safe and has similar longitudinal outcomes but is associated with less blood product usage and faster recovery than conventional CABG surgery.

Revascularization strategies for patients with stable coronary artery disease

Patients with coronary artery disease who have prognostically significant lesions or symptoms despite optimum medical therapy require mechanical revascularization with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) or both. In this review, we will evaluate the evidence-based use of the two revascularization approaches in treating patients with coronary artery disease. CABG has been the predominant mode of revascularization for more than half a century and is the preferred strategy for patients with multivessel disease, especially those with diabetes mellitus, left ventricular systolic dysfunction or complex lesions. There have been significant technical and technological advances in PCI over recent years, and this is now the preferred revascularization modality in patients with single-vessel or low-risk multivessel disease. Percutaneous coronary intervention can also be considered to treat complex multivessel disease in patients with increased risk of adverse surgical outcomes including frail patients and those with chronic obstructive pulmonary disease. Improvements in both CABG (including total arterial revascularization, off-pump CABG and 'no-touch' graft harvesting) and PCI (including newer-generation stents, adjunctive pharmacotherapy and intracoronary imaging) mean that they will continue to challenge each other in the future. A 'heart team' approach is strongly recommended to select an evidence-based, yet individualized, revascularization strategy for all patients with complex coronary artery disease. Finally, optimal medical therapy is important for all patients with coronary artery disease, regardless of the mode of revascularization.

Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease†

OBJECTIVES

Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI.

METHODS

In total, 90 AHR patients [median age 62 years (35-86)] were compared with 90 CHR patients [median age 60 years (35-85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated.

RESULTS

No perioperative deaths occurred either in the AHR group or in the CHR group, rates of myocardial infarction (3.3% vs 3.3%, P = 0.196) were similar between CHR and AHR. Operative times were longer in the AHR group [337 (137-794) min vs 272 (148-550) min, P = 0.002] and conversion rates slightly higher (P = 0.060); however, intensive care unit length of stay (P = 0.162) and hospital length of stay (P = 0.238) were similar. There was no difference in the follow-up survival (P = 0.091), freedom from angina (P = 0.844), PCI target vessel revascularization (P = 0.563), TECAB target vessel revascularization (P = 0.135) and MACCEs (P = 0.601) between CHR and AHR at follow-up. No differences were detected between the three variations of AHR in perioperative outcome, mid-term survival, freedom from MACCEs and reintervention. Neither the number nor type of TECAB/PCI targets, nor the sequence of interventions were significant predictors for MACCEs at follow-up.

CONCLUSIONS

AHR yields comparable results with CHR and can be taken into consideration as a sternum-sparing technique for the treatment of MV-coronary artery disease in selected patients.

Practice Patterns and Clinical Outcomes After Hybrid Coronary Revascularization in the United States

Background—

Hybrid coronary revascularization (HCR) involves a combination of surgical and percutaneous techniques, which in selected patients may present an alternative to conventional coronary artery bypass grafting (CABG).

Methods and Results—

Patients were included who underwent HCR (staged/concurrent) or isolated CABG in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2011 to March 2013). HCR represented 0.48% (n=950; staged=809, concurrent=141) of the total CABG volume (n=198 622) during the study period, and was performed in one-third of participating centers (n=361). Patients who underwent HCR had higher cardiovascular risk profiles in comparison with patients undergoing CABG. In comparison with CABG, median sternotomy (98.5% for CABG, 61.1% for staged HCR, and 52.5% for concurrent HCR), direct vision harvesting (98.9%, 66.0%, and 68.1%) and cardiopulmonary bypass (83.4%, 45%, and 36.9%) were less frequently used for staged and concurrent HCR, whereas robotic assistance (0.7%, 33.0%, and 30.5%) was more common. After adjustment, no differences were observed for the composite of in-hospital mortality and major morbidity (odds ratio, 0.93; 95% confidence interval, 0.75–1.16; P =0.53 for staged HCR, and odds ratio, 0.94; 95% confidence interval, 0.56–1.56; P =0.80 for concurrent HCR in comparison with CABG). There was no statistically significant association between operative mortality and either treatment group (odds ratio, 0.74; 95% confidence interval, 0.42–1.30; P =0.29 for staged HCR, and odds ratio, 2.26; 95% confidence interval, 0.99–5.17; P =0.053 for concurrent HCR in comparison with CABG).

Conclusion—

HCR, either as a staged or concurrent procedure, is performed in one-third of US hospitals and is reserved for a highly selected patient population. Although HCR may appear to be an equally safe alternative for CABG surgery, further randomized study is warranted.

Comparison of hybrid coronary revascularization versus coronary artery bypass grafting in patients≥65 years with multivessel coronary artery disease

Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery-to-left anterior descending coronary artery grafting with percutaneous coronary intervention of non-left anterior descending coronary arteries. The safety and efficacy of HCR in patients≥65 years of age is unknown. In this study, patients aged≥65 years were included who underwent HCR at an academic center from October 2003 to September 2013. These patients were matched 1:4 to similar patients treated with coronary artery bypass grafting (CABG) using a propensity-score matching algorithm. Conditional logistic regression and Cox regression stratified on matched pairs were performed to evaluate the association between HCR and CABG, and 30-day major adverse cardiovascular and cerebrovascular events (a composite of mortality, myocardial infarction, and stroke), periprocedural complications, and 3-year all-cause mortality. Of 715 patients (143 of whom underwent HCR and 572 CABG) in the propensity score-matched cohort, rates of 30-day major adverse cardiovascular and cerebrovascular events were comparable after HCR and CABG (5.6% vs 3.8%, odds ratio 1.46, 95% confidence interval 0.65 to 3.27, p=0.36). Compared with CABG, HCR resulted in fewer procedural complications (9.1% vs 18.2%, p=0.018), fewer blood transfusions (28.0% vs 53.3%, p<0.0001), less chest tube drainage (838±484 vs 1,100±579 cm3, p<0.001), and shorter lengths of stay (<5 days: 45.5% vs 27.4%, p=0.001). Over a 3-year follow-up period, mortality rates were similar after HCR and CABG (13.2% vs 16.6%, hazard ratio 0.81, 95% confidence interval 0.46 to 1.43, p=0.47). Subgroup analyses in high-risk patients (Charlson index≥6, age≥75 years) rendered similar results. In conclusion, although the present data are limited, we found that in older patients, the use of HCR is safe, has fewer procedural complications, entails less blood product use, and results in faster recovery with similar longitudinal outcomes relative to conventional CABG.

Atrial Fibrillation After Robotic Cardiac Surgery

Atrial fibrillation is one of the commonest complications after cardiac surgery and it is associated with considerable morbidity and increase in mortality. Recently, robotic approach to many heart operations has become feasible and reproducible. We here investigate and review the incidence of atrial fibrillation after robotic cardiac surgery. We found that its incidence is overall low and less than in conventional heart surgery.

The impact of clopidogrel therapy on postoperative bleeding after robotic-assisted coronary artery bypass surgery

OBJECTIVES

The purpose of this study was to determine whether patients undergoing robotic-assisted coronary artery bypass graft surgery (CABG) on clopidogrel had an increased risk of bleeding complications compared with those not on clopidogrel.

METHODS

From 2008 to 2011, 322 patients underwent robotic-assisted CABG either as an isolated procedure or as part of a hybrid coronary revascularization procedure (HCR). Patients were classified according to whether they received clopidogrel within 5 days of surgery or intraoperatively (n = 64) compared with those who never received or who had discontinued clopidogrel therapy >5 days before surgery (n = 258). A propensity analysis using 31 preoperative variables was used to control for confounding variables. In a subgroup analysis, patients undergoing one-stage HCR (clopidogrel load 600 mg in odds ratio (OR) prior to stenting) were compared with patients in the clopidogrel group who underwent two-stage HCR.

RESULTS

In the Clopidogrel group, the mean interval between surgery and last dose of clopidogrel was 2.1 ± 1.5 days. Compared with the No Clopidogrel group, the Clopidogrel group had greater 24-h chest tube drainage (1003 ± 572 vs 782 ± 530 ml, P = 0.004) and more blood transfusions (35.9%, 23 of 64 patients vs 20.9%, 54 of 258 patients, P = 0.01). On logistic regression analysis, there was greater 24-h chest tube drainage in the Clopidogrel group (+198 ml, P = 0.02) and a significantly higher incidence of blood transfusion (OR = 2.30, P = 0.01). In the subgroup analysis, patients undergoing one-stage HCR (n = 17) had greater 24-h chest tube drainage compared with patients undergoing two-stage HCR (1262 vs 909 ml, P = 0.03).

CONCLUSIONS

Patients undergoing robotic-assisted CABG on clopidogrel had more postoperative bleeding and a higher incidence of blood transfusion. Therefore, despite a less invasive approach, surgery should be delayed in these patients when possible.